Lives in your hands
The deployment of defibrillators in dental practices has put staff in the frontline as potential life-saving first responders. But a recent incident has raised practical issues
By and large, life in a dental clinic is free of incidents of high drama. However, all that changed for Dr Stuart McLaren, a dentist in Rutherglen, Glasgow, on the day in October this year when his dental associate received a phone call out of the blue from the Scottish Ambulance Service.
A man had suffered an out-of-hospital cardiac arrest – something that happens in Scotland nearly 9,000 times a year – on the street just around the corner. Like all dental practices in Scotland, Stuart’s surgery was officially listed as a first responder in cases of emergency, so he and his associate, Natalie Graham, grabbed their defibrillator, oxygen, emergency kit and gloves and rushed out to the scene.
Bystanders were already performing CPR, when Stuart, who is the principal at the local Prestige Dental Clinic, quickly took over and unpacked the defibrillator and its pads. “I applied a shock and then started to clear the man’s airway,” he recalls. “He had a Miami J cervical collar on his neck, indicative of recent spinal injury, and that made his airway control significantly harder, plus there was an open head wound he’d sustained as he fell.”
Four shocks were delivered before the paramedics arrived eight minutes later. With CPR continuing, the patient was stretchered into the ambulance and away to hospital. Sadly, he did not survive.
“AS I’m an A&E Doctor, I know how the kit works, but everyone in a clinic needs to know”
As a first responder, Stuart was ideally qualified to deal with the situation: as well as being a dentist, he is also a qualified doctor in emergency medicine, working regularly in the accident and emergency department at the city’s Queen Elizabeth University Hospital. In addition, he is a clinical lecturer at the University of Glasgow.
The incident highlighted the importance of the Scottish Government’s strategy of equipping dental practices with defibrillators as a matter of routine. Funding is provided, and staff are then meant to use their own expertise in administering the treatment required.
However, after using the defibrillator equipment for the first time, Stuart believes that the system, while well intentioned, does have some deficiencies and that there are useful lessons to learn from his own practical experience.
“The hardware is provided, but you also need things like gloves and to remember to keep them as part of your emergency kit,” he says, “We do that, but these things are not provided with the defibrillator and I don’t think other dental clinics would necessarily have these in their pack as essential additional items, ready to go.”
Another issue he identifies is that on returning to the practice, the defibrillator pads supplied, which are for a single incident only, had then been used. “We then had to ask if we should shut down for the rest of the day as we couldn’t treat another cardiac arrest case if one came up. We’d used our pads and that was it until we got hold of more.
“I’ve spoken to colleagues about this since and no-one really thinks about having to buy another two or three sets in case this happens. The defibrillator only comes with one set.
“Obviously this isn’t about the money, but when I asked about the issue of reimbursement for defibrillator pads, the clinical director recalled that it was agreed with the Scottish Government that practices should be reimbursed for these items but the mechanism for doing this is unclear.
“I was advised that the dental practice advisors’ group will meet with the Scottish Government soon, and as the details outlined are causing concern across all health boards, they are on the agenda for discussion.”
“you want to give the patient the best chance you can”
The incident also taught him about the importance of having all potentially necessary equipment in one rucksack. “My airway adjuncts were with another oxygen cylinder and my associate had to go back to the clinic and get those. It would obviously be better to have everything pre-packed and ready to go but you have to organise
“You want to give the patient the best chance you can. When we arrived, they may not have been medically evaluated. They might not be in full cardiac arrest or might need further attention when they come round. You need more than the defibrillator.”
The experience taught him another thing: the human emotional impact of having to deal with this kind of emergency. “People could be dying or actually dead in front of you. The health board was quite supportive in this and said counselling was available if needed. We had a debrief later and Natalie had said the adrenaline carried her through at the time, but she hadn’t managed to sleep a wink that night.”
Use of the defibrillators also raises practical questions about the availability of training. Dental practices have update sessions on life support annually, as do other workplace environments both inside and outside medicine, but this equipment may not be covered as part of these. In general, the amount of training received is assessed as a tick-box exercise, but the quality of that training is not scrutinised.
Stuart thinks this is an issue that needs to be addressed. He also believes that some of his colleagues in other Scottish dental practices are apprehensive of the defibrillator. “We actually had ours before the general availability of funding for them in 2015, as we carry out sedation in the surgery and need that advanced life support knowledge and equipment. So we’re familiar with it.
“Also, as I’m a practicing A&E doctor, I know how the kit works. But everyone in a clinic needs to know how a defibrillator should be operated. It might be, for instance, that the dentist is on a course and so it’s the nurse that is called out when an emergency arises. We should perhaps all look at increasing our proficiency when it comes to this.”
Restart a Heart Day success
The European Resuscitation Council event in October for World Restart a Heart Day was a huge success in Scotland where the dental faculties of Dundee, Edinburgh and Glasgow linked up to deliver training in the life-saving skill of CPR.
The day also raised public awareness on out-of-hospital cardiac arrest and the availability of defibrillators held within general dental practices, which are also public access defibrillators and mapped with the Scottish Ambulance Service.
It is hoped that by training members of the public, the survival rates from an out-of-hospital cardiac arrest will increase and get closer to the Scottish Government target of an additional 1,000 lives saved and 500,000 people trained by 2020.
The joint event trained 369 members of the public, which was a significant achievement – 104 were trained in Dundee, 75 in Edinburgh and 191 in Glasgow.
Lezley Ann Walker, dental team tutor at Glasgow Dental Hospital and School, who organised the event, hopes to expand and link with more dental colleagues and increase the numbers.